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General NPI Number Information
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NPI Number | 1003861188
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Entity Type | Organization
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Legal Business Name | LAKESHORE MEDICAL CLINIC, LLC
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Dates
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Enumeration Date | 05/24/2006
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Last Update Date | 10/03/2025
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Provider Practice Location Address
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Address Line | 2000 E LAYTON AVE STE 100
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City | SAINT FRANCIS
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State | WI
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Zip | 53235-6054
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Country | US
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Telephone | 414-744-6589
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 735044
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City | CHICAGO
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State | IL
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Zip | 60673-5044
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Country | US
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Telephone | 414-647-6326
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Fax |
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Authorized Official
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Title or Position | ASSISTANT TREASURER
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Name | KARA RICHARDSON
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Credential |
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Telephone | 704-631-0450
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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